Incident investigation·October 22, 2025

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a case management inspection related to a recent incident report submitted to the Department. LPA met with Janeyn Kelly, Administrator, and explained the purpose of today's inspection. Also present was Jhamil Espino and Nikolas Martinez, caregivers. LPA observed (4) residents present during the inspection and was advised (1) resident was currently receiving medical care outside of the facility. LPA and Administrator discussed the incident report submitted to the department on October 14, 2025 regarding resident (R1) sustaining a skin tear on October 10, 2025. While staff was providing incontinent care and repositioning resident, (R1) sustained a skin tear on the top of their right hand near the thumb. Staff believed it was caused from a metal clip on the bed remote cord that was attached to the bed rail but has been removed following the incident. The caregiver immediately applied pressure to the skin tear and contacted the administrator who provided first aid treatment. The facility contacted the hospice nurse and family member also. The hospice doctor visited (R1) the following day, October 11, 2025, and did not see any concerns that the nurse could not handle. (R1) has nursing visits with a hospice nurse at least twice weekly and a home health aide five times week. LPA observed a home health aide arrive during today's inspection. LPA observed (R1) to have a clean, wrapped bandage over the area of their right hand and to be comfortably resting in bed. The administrator stated (R1) has not complained of any pain and is not able to take the bandage off anymore since earlier this week when the nurse used additional first aid tape. LPA toured the facility and observed it to be clean, orderly and without any odors. The residents appeared to all be comfortably resting after breakfast. The facility promptly responded by applying first aid care and notifying hospice and the family following the incident. The facility will continue to monitor (R1's) right hand. There are no deficiencies issued in this report. Exit interview. Copy of report provided.